Unique Plan Description: CT Surg Epicardial Surgical Ablation ERA Post op (MH)
Plan Selection Display: CT Surg Epicardial Surgical Ablation ERA Post op (MH)
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2020-03-02 09:52:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-08-01 11:26:40
Available at all facilities: Yes

CT Surg Epicardial Surgical Ablation ERA Post op (
Vital Signs
	Vital Signs
		T;N, Routine post op
Activity
	Dangle
		T;N
			Comment: one time, 2 hours post extubation
	Ambulate
		T;N, QID
			Comment: increase distance as tolerated
	Up in Chair
		T;N+120, Once
			Comment: 4 hours after arrival to floor
		T;N, TIDWM
			Comment: start post op day 1 when stable
	Elevate head of bed
		Elevate head of bed 30 degrees
Diet
	Clear Liquid Diet
		T;N
			Comment: Clear liquids only until tolerated, then advance as tolerated to Regular diet.
Laboratory
	CBC with Diff
		T+1;0400, Routine, spec type = Blood
	Basic Metabolic Panel
		T+1;0400, Routine, spec type = Blood
	Glucose POC - RN
		T;N, Once
			Comment: upon arrival to room. if greater than 180 initiate sliding scale moderate dose Novolog insulin.
		QIDACHS
Diagnostic Tests
	Chest 1 View
		Stat, Post Op F/U
			Comment: In PACU
		T+1;0400, Routine, Post Op F/U, Portable
IV Solutions
	Sodium Chloride 0.9%
		1,000 mL, IV, T;N, 80 ml/hr
			Comment: x1 bag, Discontinue when bag completed
Medications
	Lasix Injection
		20 mg, Injection, IV Push, Once, T+1;0900
		40 mg, Injection, IV Push, Once, T+1;0900
	ibuprofen
		600 mg, Tab, By Mouth, Q6H
			Comment: Do not give if systolic bp <90 or if serum creatinine is >1.5mg/dl (or creatinine clearance <50ml/min. Notify MD of any dose not given.  Do not give with Toradol concomitantly.
	Protonix
		40 mg, Tablet-Enteric-Coated, By Mouth, DAILY
			Comment: start evening of OR
	acetaminophen 10 mg/mL intravenous solution
		1,000 mg, Solution-Injection, IVPB, Q8H, for see comment, duration: 3 Dose(s)/Time(s)
			Comment: start 4 hours after any pre-op/intra-op dose or immediately post-op if no dose.
	Tylenol
		650 mg, Tab, By Mouth, Q4H, PRN headaches
			Comment: Scheduled medication. Start after scheduled IV APAP complete.  Do not give both oral and IV APAP.
	gabapentin
		100 mg, Capsule, By Mouth, TID
			Comment: Start evening of surgery. Do not give if >75 years old. Pharmacy to adjust for renal function.  If patient takes at home restart home dose.
		NSAIDs cannot be used (ARE CONTRAINDICATED) in the following cases:  Allergy to aspirin or any NSAID, During pregnancy, During breast feeding, On blood thinning agents (anticoagulants), Suffering from a defect of the blood clotting system (coagulation)(NOTE)*
	colchicine
		0.6 mg, Tab, By Mouth, BID
			Comment: start evening of OR
		0.6 mg, Tab, By Mouth, DAILY
			Comment: If patient <70kg, start evening of OR
	methylPREDNISolone
		24 mg, Tab, By Mouth, QPM, duration: 1 Dose(s)/Time(s)
			Comment: Give evening of surgery, Patient to use own Dose pak
		20 mg, Tab, By Mouth, QAM, duration: 1 Dose(s)/Time(s)
			Comment: Give morning POD 1, Patient to use own Dose pak
		16 mg, Tab, By Mouth, QAM, duration: 1 Dose(s)/Time(s)
			Comment: Give morning POD 2, Patient to use own Dose pak
		12 mg, Tab, By Mouth, QAM, duration: 1 Dose(s)/Time(s)
			Comment: Give morning POD 3, Patient to use own Dose pak
		8 mg, Tab, By Mouth, QAM, duration: 1 Dose(s)/Time(s)
			Comment: Give morning POD 4, Patient to use own Dose pak
		4 mg, Tab, By Mouth, QAM, duration: 1 Dose(s)/Time(s)
			Comment: Give morning POD 5, Patient to use own Dose pak
	oxyCODONE
		5 mg, Tab, By Mouth, Q4H, PRN for pain-moderate
			Comment: for pain rated 4 or greater and greater than patient stated comfort goal after scheduled medications given. Give for pain rated 4-6. Note pain score before and after administration; may cause drowsiness.  Goal of ERAS order set is to limit opiates as they have a deleterious effect on return of bowel function Please limit the administration of opiates unless the pain score is more than 5 if possible.
		10 mg, Tab, By Mouth, Q4H, PRN for pain-severe
			Comment: for pain rated 4 or greater and greater than patient stated comfort goal after scheduled medications given. Give for pain rated 7-10. Note pain score before and after administration; may cause drowsiness.  Goal of ERAS order set is to limit opiates as they have a deleterious effect on return of bowel function Please limit the administration of opiates unless the pain score is more than 5 if possible.
	morphine  IV
		4 mg, Syringe, IV Push, Q2H, PRN for pain-severe
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
	ketorolac injectable
		15 mg, Injection, IV Push, Q8H, PRN for pain-moderate
			Comment: For pain rating 7-10; may give if NPO or for breakthrough pain if on oral analgesics.
		7.5 mg, Injection, IV Push, Q8H, PRN for pain-mild, duration: 2 Dose(s)/Time(s)
			Comment: May repeat x 1 (for total of 15mg).  Do not give Ibuprofen concomitantly.
Constipation
	docusate
		100 mg, Capsule, By Mouth, DAILY
			Comment: Hold for diarrhea
	Senokot S 50 mg-8.6 mg oral tablet
		2 TAB, Tab, By Mouth, QHS
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, DAILY
			Comment: Mix in 6 oz juice or water
	Milk of Magnesia 8% oral suspension
		30 mL, Suspension, By Mouth, DAILY, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
		30 mL, Suspension, By Mouth, Q12H, PRN for constipation
			Comment: If Miralax not effective; do not use if creatinine clearance or GFR < 30mL/min
	Dulcolax
		10 mg, Suppository, RECTALLY, DAILY, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
		10 mg, Suppository, RECTALLY, Q12H, PRN, constipation
			Comment: If MOM ineffective or if patient NPO
	Fleet Enema 19 gm-7 gm rectal enema
		1 EA, Enema, RECTALLY, Q12H, PRN, constipation
			Comment: If bisacodyl ineffective
	Enema-Administer
		Tap water, Q1H, constipation
			Comment: if suppository ineffective
Nausea Vomiting
	ondansetron
		4 mg, Injection, IV PUSH, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		4 mg, Tablet-Disintegrating, BY MOUTH, Q6H, PRN for nausea and/or vomiting
			Comment: Administer for nausea if not previously administered by anesthesia, PACU, or ED
		Select either promethazine or prochlorperazine orders(NOTE)*
	prochlorperazine
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures, give if IV access not available.
	Phenergan (MH/WH)
		25 mg, Tab, By Mouth, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures.
		25 mg, Suppository, RECTALLY, BID, PRN, nausea and/or vomiting
			Comment: Give if ondansetron ineffective and if no history of seizures; give if unable to take oral meds.
	Reglan
		10 mg, Injection, IV Push, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
		10 mg, Injection, IM-Intramuscular, Q6H, PRN, nausea and/or vomiting
			Comment: Give if ondansetron and phenothiazine ineffective; avoid in patients > 65 y/o.
Patient Care

	Resuscitation Status
		Full Code
		No Code
	Cardiac Telemetry Monitoring
		Telemetry Indications: ACS/Arrhythmia/QTc
	Chest Tube
		Maintain water at 20cm H2O
			Comment: may ambulate off suction as tolerated, if no air leak.
	Incentive Spirometer
		T;N, Per protocol
	Notify MD
		if SBP <100 or >150, HR <50 or >120, urine output <50ml/hr for 2 hours, temp >101, SaO2 <90%.
	VTE Advisor
		Thoracic surgery
	Dressing Care
		Change, chest tube, Q48H
			Comment: and as needed
		Change, chest tube
			Comment: PRN, as needed
		T+2;0600, Remove, Routine post op, 2, Day(s)
			Comment: Remove dressing. Apply dressing PRN incisional dressing.
	Wound Drain
		T;N, Q1H, 8, hr
			Comment: milk q1h or as needed
		T;N+480, Q4H-Sch, 8, hr
			Comment: milk q4h or as needed
	Intake and Output
		T;N, Q1H, 4, Dose(s)/Time(s)
			Comment: strip bulb suction
		T;N+240, Q2H-Sch, 4, Dose(s)/Time(s)
			Comment: strip bulb suction
		T;N+720, Q4H-Sch
			Comment: strip bulb suction
		T;N+1160
			Comment: Routine
	Patient Education
		T;N, Instructions: Chest splinting
	Incentive Spirometer
		T;N, Q1HAWAKE
			Comment: Per protocol
		T;N, Q2HAWAKE
			Comment: Per protocol
	Cough, Deep Breathe
		T;N, Q1HAWAKE
		T;N, Q2HAWAKE
	Discontinue Arterial Line
		T+1;0600
			Comment: in PACU if extubated, hemodynamically stable and transferring to floor
	Discharge Instructions Other
		Instructions: follow up with MPC EP Cardiologist at 6 weeks.
	Notify MD
		If patient develops itching
		if no results from enema.
	Straight Catheter
		T;N, Insert, PRN x2, unable to void
Therapies
	Oxygen Therapy
		T;N
	Pulse Oximetry Spot Check RT
		T+1, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
			Comment: 24hrs. discontinue post op day 1, then spot check BID
Consults/Follow-up
	Consult Social Work
		Discharge Planning
	Consult EP Cardiologist
		Reason for Referral: admission, Refer to/Consult with: MPC EP Cardiologist
	Consult Cardiac Rehab: Inpatient
		T+1;0600

Peripheral Lock - Access
Medications
	sodium chloride 0.9% flush injectable soln
		10 mL Syringe IV PUSH BID
		10 mL, Syringe, IV PUSH, Q5MIN, PRN, IV line flush
	lidocaine 1% injectable solution (MH/WH/FH)
		0.1 mL, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start
	sodium chloride bacteriostatic 0.9% injectable soln
		0.1 mL, Injection, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start, use if patient has lidocaine allergy.
	Sodium Chloride 0.9% IVPB Flush
		25 mL, IVPB, Q1H, PRN, IV line flush, 5 min(s)
			Comment: Use if medication not compatible with primary line or there is no primary line;  infuse 25mL.
Patient Care
	Peripheral Lock-Insert
		T;N

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase